The Key to Preventing C. difficile? Reducing Antibiotics—Part 3

Known to cause around 250,000 infections per year, and a staggering 14,000 deaths, it is not surprising that Clostridium difficile (C. diff) has been given a threat level of urgent by the Centers for Disease Control and Prevention. Preventing transmission of this life-threatening infection continues to be a difficult challenge faced by health care workers everywhere.

There are many risk factors for C. diff infection (CDI), which include underlying conditions/comorbidities, individuals with disease states such as cardiopulmonary disease and diabetes, and, arguably most importantly, antibiotic exposure.

In an exclusive interview with Contagion ^®, Maureen Spencer, RN, BSN, MEd, CiC, FAPIC, director of clinical implementation at Accelerate Diagnostics, discussed the importance of infection prevention, the role that reducing antibiotics plays in preventing CDIs, and how any successful prevention effort requires teamwork.

Contagion^®: As an infection preventionist (IP), can you explain the importance of prevention, especially when it comes to a healthcare-associated infection like C. diff?

Spencer: A lot of our job should be prevention, but we still end up handling infection control efforts. They changed our title years ago from infection control practitioners to infection preventionists, and yet, when you hear most of the things being spoken about at conferences like this, we’re talking about the control of the environment, of people using precautions, and of treating patients’ infections.

The prevention aspect is to stop the inappropriate use of antibiotics. If we didn’t use so many antibiotics, we wouldn’t have conditions like this developing. That’s the prevention piece of it—the antimicrobial stewardship program (ASP), and having infection preventionists actively involved in taking on antimicrobial resistance and assisting the ASP program members with reducing the number and length of treatments, or days of therapy with the antibiotics. That is what causes these multidrug-resistant organisms (MDROs) and C. diff.

Contagion: What’s a major way to prevent CDIs?

Spencer: Decreasing the use of antibiotics. Many laboratories are using older, traditional methods of doing cultures, and it can take anywhere from 2 to 3 days to get not only the culture itself speciated out and colonies picked off, but to put it into some identification (ID) system—whether it be PCR or some other kind of rapid technology. Then they go on to do sensitivities that can take anywhere from 2 to 4 to 5 days, depending on the specimen. In the interim, patients are on antibiotics waiting for the results. I feel that it’s the number one problem we have in hospitals—delayed lab results.

For example, you’ve got somebody in septic shock in the intensive care unit (ICU). We are wiping out all the good flora in their mouth, their colon, and their skin being on antifungal, anti-Gram-positive, anti-Gram-negative, and even sometimes double therapy, while physicians are covering their tails. The physician doesn’t know what [infection the patient] has, and so they want to give them everything. We call that empiric therapy. After physicians get the lab results, they can de-escalate the patient and then get to more targeted therapy. For instance, rather than use imipenem, which is more expensive, the physician can maybe switch to gentamicin based on a sensitivity result and have the patient on something that’s safer and less expensive.

[To help with faster lab results,] there is new technology that has come out that’s available. These are fast ID and susceptibility systems, and IPs have to work with the lab to support them. [Adopting these technologies] should be driven from the clinical side, with IPs supporting the lab to get this technology. What often happens, though, is a disconnect between IPs and the lab, because everything goes into electronic medical records (EMRs). And so, IPs get EMRs in their offices, and they’re able to look at all the cultures from there. In the old days, we would go to the lab in the morning, find out what was going on with gram stains and blood cultures and any unusual organisms, then head up to the ICU and see all the sickest patients, and do our rounds. Now, the IPs are chained to their desks, doing surveillance for the CDC’s National Healthcare Safety Network (NHSN), and not going out doing what they should be doing—which is surveillance out on the floors consulting, providing education, and visiting departments. It’s created a big crisis in infection prevention—the NHSN system—without the support IPs should have had for data analysts to help us navigate the system.

The laboratory needs support, too, probably through the ASP committee. Through that committee we can all make a case for the lab to get a very rapid system. If we have the PharmD showing the days of therapy and how they could reduce it, the IPs reducing the adverse outcomes, and nursing and critical care and sepsis coordinators all making a business case so that the lab—whose budget is going to go up—can be left alone, then we can say, ‘We’re going to support you clinically.’ But that’s not what happens. Often, it’s left to the lab, and the lab gets shut down.

There’s also a new machine available that will do a blood culture from a half a cc of positive blood, the Accelerate Pheno System. It will automatically identify an organism and its sensitivity within 7 hours, whereas typically, you wait anywhere from 2 to 5 days. When that kind of technology comes out and starts to get adopted in more hospitals, then patients—who are getting more savvy these days—can say, ‘You didn’t use the more rapid, fast technology, and I got an infection because I sat waiting for days; I got C. diff on top of it.’ There are now some legal suits that are going along those lines. Patients are feeling that they’re not having the advantage of some of this more rapid and fast technology for either ID of the organism alone, or the antimicrobial sensitivity. This new system combines the two together.

Contagion: Can you speak to the importance of teamwork when it comes to the fight against C. diff?

Spencer: [The fight] requires a team, and the team should include, or at least try to get, members from the chief of surgery (they’re going to be doing colectomies on patients who have CDI), the chief of gastroenterology (since we see a higher correlation of CDIs with proton pump inhibitors and with endoscopy procedures), and nurse managers (especially the nurse manager of the unit that might deal with more of the patients coming in from long-term care and being on [contact] precautions). [The team should] have members of the microbiology lab there, too, as well as the infection preventionists, and the quality department (since they’re responsible for all the penalties that we are getting from the Centers for Medicare & Medicaid Services for CDI cases). Also, environmental services (EVS) should be there, if there is some of this innovative technology that they would have to know or you intend to install special lights and fixtures.

What the team should do at first is get everybody on the same page with education. There are a couple of good epidemiology articles on CDIs to provide everyone with, to ensure they understand this national crisis with C. diff. Then, from there, developing different tasks and projects for the group members and reviewing different cases are important as well. Talk about, ‘Why did this person likely get a CDI? Does it look like it was due to the antibiotics? Or, could this [patient] have been somebody who wasn’t on antibiotics, but picked it up while they were in the hospital as a cross-contamination case?’ That would be the role of the infection preventionist: to bring those cases forward and present them to the committee.

To read the first part of the interview on preventing and controlling CDIs in hospital, go here.

You can read the second portion of the interview on the challenges to disinfecting hospital rooms to prevent CDIs, here.